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Returned Claims
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Q What happens when a claim is returned for additional information?
A

There are many reasons why a claim is returned for additional information. If additional information is needed, the entire claim will be returned to the party who submitted it. The claim will be accompanied with a letter detailing the information needed to complete processing.

Some of the top reasons that a claim could be returned for additional information are:

  • Services required a prior authorization or referral and one is not on file. Medical documentation will be requested so that medical necessity of the services or inpatient admission can be established.
  • Other health insurance. As a government program, TRICARE is secondary to all insurance. The only exceptions to this are TRICARE supplements and Medicaid. If our records indicate a primary insurance and a claim is submitted without evidence of those services being processed by the primary insurance, the claim will be returned.
    It is important that our claims processing records are current. If you no longer have primary insurance or there is a change in your primary insurance, please make sure you contact our Customer Service department.
  • The beneficiary is enrolled in another region. The beneficiary's permanent home address or enrollment within another region determines processing jurisdiction.
  • The provider did not properly sign the claim. Signature on file is not an acceptable signature for a provider.
    To determine the specific reason why the claim was returned, please contact Customer Service. If you are aware of what information is needed, please resubmit that information along with a completed claim form.